My favorite quotes for American health care, especially for rural areas:
I intend to tell you what this "right thing" is. I will help you get through the rhetoric that protects those who could make a difference but choose not to. I will back it up with outcomes. I will describe the decisional paralysis we must overcome. And I will give examples as to how to do it.
“[There is] a trend towards a progressive deterioration in health as one moves from that area bordering urban centres into the very remote hinterland" - Canadian rural situation - Pampalon, 1991
As we all know, many Americans living in rural and inner-city areas do, indeed, have limited or no access to physicians' services. Jordan Cohen, M.D., President of AAMC
Rural communities are particularly vulnerable to the uncertainty this situation (delegating defense against disease to complex health care systems) can cause becaue their health care systems are fragile, often controlled by people whose roots and orientations are alien to the community. Yet, paradoxically, it is in rural areas, where greater proportions of the poor and elderly populations live, that health care services are most needed. Rosenblatt and Moscovice 1982 Rural Health Care. John Wiley and Sons, New York, 1982
Major changes in the distribution of physician services will not come about until policies that are designed to redistribute medical services recognize that a major locus of the problem is in general differences between communities and not solely in the attitudes, motives, values, and other personal characteristics of individual physicians. William A. Rushing, 1975
The complaint that doctors don't choose to practice in these (underserved) locations is valid. What is invalid is the expectation that the mere existence of a need for physicians' services will suffice to offset the many disincentives faced by physicians who might otherwise respond to that need. There are many factors beyond a given community's need for doctors that individual physicians must weigh in deciding whether to set up practice there. Jordan Cohen, M.D., President of AAMC
Finally, even if economic considerations can be met, the social and cultural characteristics of most medically underserved areas present daunting obstacles to many physicians who might contemplate practicing there. .......a paucity of satisfying cultural and civic outlets naturally enter the calculation when young physicians weigh their practice options Jordan Cohen, M.D. President of AAMC
I believe, along with many others, that we can solve the geographic maldistribution problem by placing fully trained U.S. graduates in underserved areas for substantial, albeit limited, periods of time. Jordan Cohen, M.D. President of AAMC
Substantial public education will be required, however, to wean many people from the notion that the only way to access quality medical care is to have a lifelong relationship with a single physician. Having a series of two- or three-year relationships with fully trained physicians is far better than nothing. As is so often the case, the quest for perfection can be the enemy of the possible. Jordan Cohen, M.D., President of AAMC
Medical leaders are missing important considerations. For example most are facing tremendous competition. The Community Driven approach has great potential long term benefits
RPAP (MN) builds bridges of good will between the University and rural doctors. Many physicians recall the days when the hapless and hopeless referring LMD was dismissed with scorn at the professor's grand rounds. Times have changed! Monthly University visits have done much to dispel the doubts. When men of professional stature… come out to the rural hospital, make rounds, break bread, and discuss common problems with the local medical staff, new bonds of understanding grow quickly between small town and gown. JK Heid
I did a 2 day visit to Minnesota with 1/2 day in a rural town. I was there to do a consult on RPAP. During the meeting, Wally Swentko introduced me to the hospital administrator. During the brief exchange, he mentioned that the 22 hospital regional effort that he represented was in great need of specialists. Had I been the dean or head of clinical operations instead of an outside consultant, things would have been different. The university would be well on the way toward new markets. Through experience I realize that rural people work in person, not by distance. Rural visits are critical for better teaching and health care. Unfortunately UMN faculty balk at doing the visits anymore, don't believe the past data noting 4 referrals for each rural visit, and don't seem to be willing to improve their potential for survival. No wonder they have had to sell out to Fairview. Not only do they lose more control, they have also had to cut back on the faculty that were more generalist in nature. This makes them even less likely to be able to meet the needs of local people, the needs of small town patients, the challenge of competing in urban environments, and the needs of medical education (as these are the specialists who are most likely to teach).. Certainly I could agree with them that new markets are unlikely in the most managed care intensive state in the US, but there is still a market for specialist services. Better relations with rural communities could do more, also residents and students would have much better treatment, if academic medical centers realized that this group represented a major source of future referrals and procedures.
Now even though Dr. Cohen needs more contact with rural communities, rural living and rural practice, he does understand about organizing medical education and gaining cooperation between those in and outside medical schools:
HOW ACADEMIC MEDICINE TOOK ACTION
The clinical faculties of medical schools, of course, -- and the teaching hospitals in which they worked - were not immune from these problems. Fortunately, however, the leaders of academic medicine decided to take some action. They realized that they had a fundamental responsibility to help chart a better health care future - not only for themselves, but for the country as a whole. They also realized that the public support crucial for sustaining their societal missions - education, research, and cutting-edge care for special populations - that support for those societal missions would remain in extreme jeopardy as long as policymakers continued to view medical schools and teaching hospitals as part of the problem, rather than as partners in finding solutions. Jordan Cohen, M.D., President of AAMC Closing the Gaps by Working Together 1999 Annual Meeting
There are many obstacles to rural visits, some real and some imagined. During a site visit to one of our RTT programs, a small plane had problems and the visitor had to deplane through the cargo exit. Not surprisingly he granted accreditation for a length just beyond his term of service.
Some Washington DC Medicare and Medicaid personnel visited Nebraska. They were comfortable with the long plane flight to Omaha, but noted, " Please don't put us on a small plane."
Small rural health systems represent a variety of ever changing environments with two endangered species: hospitals and practitioners. Those who would treat rural communities with the disease of "retentionitis" would do well to learn from experienced healers such as Sir William Osler who said that prescribing external remedies is far less important than understanding the lifestyle and habits of the patient. Robert C. Bowman, M.D. 1997
Many of us thought the battle for Family Practice was over. We are finding that the battles have just begun. It is a hard road that we have to travel. Family practice has survived creation and vision, it must survive revision and complacency - Robert C. Bowman, M.D. 2000
More than 4 times in the past 2 months I have heard faculty or family medicine leaders express reticence to get more involved with the safety net and underserved communities, mainly because the reimbursement is so bad.
It is no longer about establishing family medicine as a discipline. The battle is much larger. It is about the kind of health care delivered in the United States and our role in shaping the caregiver that will best serve our patients. This is no easy task because the general awareness of these issues is low. - Robert C. Bowman, M.D. 2000
Have we forgotten the underserved that brought us to creation. Family practice graduates choosing rural locations continue at the same 600 per year. This is no different now than shortly after our re-creation. This has occurred even though we have tripled the numbers of FP graduates. Graduate numbers choosing urban poverty locations are on the decline in recent years. Have we become part of those who exploit rather than those who contribute? Are we increasing the experiences that will lead our graduate to choose underserved locations? Robert C. Bowman, M.D. 2000
I would speak of [the general practitioner’s] failure to realize first the need of a lifelong progressive personal training, and secondly, the danger lest in the stress of practice he sacrifice that most precious of all possessions, his mental independence. "Chauvinism in Medicine," Montreal Medical Journal, 31:684, 1902.
In no profession does culture count for so much as in medicine, and no man needs it more than the general practitioner. "Chauvinism in Medicine," Montreal Medical Journal, 31:684, 1902.
Do we worry about the potential financial problems regarding care of the indigent and those with medicaid and medicare?
Our outpatient care center with a significant component is outstripping all of our "paying" clinics for patient visits.
Why not make the underserved paying citizens - Lincoln program and others
Why does the country continue to allow areas to suffer the triple threat of poverty, poor education, and poor health care?
Why does Family Medicine cling to Title VII and GME that fails to address the needs of family medicine as well as underserved communities? Take a leap and join the Safety Net.
“Rural practitioners are much more likely to be looking after individual patients for all their medical problems on a continuing basis and to be caring for other family members." -WONCA Policy on Training for Rural Practice 1995
The best places to learn are not always the most convenient places to teach -, FP faculty, researcher, educator, counselor, friend 2001
Many FP faculty are specialists in a number of areas. Also Family Medicine itself has taken a specialty focus. Training situations that involve longer or more urban training have resulted in fewer going into rural practice, as noted by Bruce and Verby in their studies.
The combination of shifting from a rotating internship requirement to a minimum two-year residency training program for family practice, together with the decisions taken about the overall mix of residency positions, have meant that fewer physicians are now leaving the training pipeline with general/family practice credentials. -Barer Stoddart 1999
If you want physicians to go to location where they need to do more caring and service than usual, you have to pick students who want to do more service and caring than usual - Robert C. Bowman, M.D. 2001
I would go for the biggest bang and one focus per year. Therefore I suggest Admissions. If we get more rural origin students in the pipeline we will get more rural docs and less burnout therefore more retention….. If your intent is to breed cocker spaniels you don't start by buying poodles. Tom Rosenthal, M.D., Editor of the Journal of Rural Health 2001
The importance of recruiting and admitting future physicians who have grown up in rural and remote settings now seems clearly established... However... only a fraction of what could be done in this area is currently being done. -Barer Stoddart 1999
No matter how successful we are in attracting idealistic, properly motivated students to medicine now or in the future, said Dr. Cohen, "we have little hope of delivering the same number of idealistic, properly motivated doctors to society unless we can close the gap between rhetoric and reality." Jordan Cohen, M.D., address to AAMC Annual 2001
With only 1% of the medical students each year in the state of Pennsylvania, Rabinowitz' PSAP program, admitted by working with small colleges to examine characteristics such as rural background is responsible for 21% of the rural family physicians in the state. Rural Background together with FP interest at matriculation is 78% of the decision for rural practice of these students. Rabinowitz, Critical Factors JAMA 2001
Medical school admission procedures should be based on institutional mission and capacity, and national health work force targets. The open entry system is obsolete" -Edinburough declaration of the World Rural Health Conference
As my sainted grandmother, Dr Mary, used to say, "There are two kinds of people. Those that do the work and those that take the credit. Bill, try to be among the first group. For one thing, there's a lot less competition to belong." Bill Rodney, M.D. 1999
AAMC GQ in 1995 data - Rural interested senior medical students (those interested in locating in a town of less than 10,000) were twice as likely to have done volunteer work locally or overseas as their peers. They were 6 times as likely to plan a practice in an underserved locations.
Providing medical care in rural and remote areas can be one of the most fulfilling, exciting, and challenging types of work that a physician could imagine. And despite the inevitable personal and professional challenges faced by their physicians, hundreds of thousands of Canadians across the country have been well-served by these dedicated professionals. -Barer Stoddart 1999
“Improved geographic distribution of medical services will require a concerted effort to create a broadly based and integrated policy package of reinforcing initiatives." -Barer-Stoddart, 1991
“In order to increase the numbers and quality of rural doctors it is necessary to implement a series of strategies aimed at establishing an integrated career pathway of education and training for rural practice." -WONCA Policy on Training for Rural Practice 1995
Health professionals education represents one of the South's major successes….. despite increases in the overall supply ….. serious problems of distribution of professionals to geographic, subspecialty, and public service areas of need continue, except for those situations in which carefully coordinated strategies have been directed to specific problems Southern Regional Education Board 1983
These efforts have been most helpful: AHEC, expansion of primary care residencies, move of rural preceptorship to earlier position, development of Office of Community Medical Affairs with its host of outreach and bridging activities. Bruce and Norton, Improving Rural Health P 165
The state of Arkansas basically had twice as much gain in the ration of physicians to population from 1975 to 1979 when compared to states throughout the south and midwest and at 18% growth, had the 5th largest growth of any state in the nation. Bruce and Norton, Improving Rural Health P 168 1984 Arkansas Approach
The Minnesota RPAP graduates just in the state of Minnesota have provided over 3 billion dollars in economic activity for the rural parts of the state. Within 6 years of the program onset, no place in Minnesota had a physician to population ratio of over 2500. Verby articles
Medical schools with even a few components of the Community Driven approach have made great strides. Assessing Community Orientation
Medical education is not just a program for building knowledge and skills in its recipients... it is also an experience which creates attitudes and expectations. Abraham Flexner 1914
“Teaching hospitals are run by doctors who have chosen a small area of medicine in which, with the aid of expensive technology, they have become expert. How can doctors be expected to feel competent or wish to practice in country areas hundreds of kilometers away from such technology." -Kamien 1984
Successful training programs include "teaching staff who work every day with physicians with patients in little towns and rural settings and hold rural physicians in high regard and honestly support students when interested in rural medicine." -Lampert 1991
No more dangerous members of our profession exist than those born into it, so to speak, as specialists. Without any broad foundation in physiology or pathology, and ignorant of the great processes of disease, no amount of technical skill can hide from the keen eyes of colleagues defects which too often require the arts of the charlatan to screen from the public. "Remarks on Specialism," Boston Medical and Surgical Journal, 126:457, 1892.
The incessant concentration of thought upon one subject, however interesting, tethers a man’s mind in a narrow field. "Chauvinism in Medicine," Montreal Medical Journal, 31:684, 1902.
By all means, if possible, let [the young physician] be a pluralist, and–as he values his future life–let him not get early entangled in the meshes of specialism. "Internal Medicine as a Vocation," Medical News, New York, 71:660, 1897.
Our medical schools are dominated by subspecialists and researchers, those whose careers are made by focusing on ever smaller areas of medicine. The specialists who have broader tendencies are often not respected or rewarded and mostly don't work for medical schools any more. These are the ones who make the best teachers from among the specialists.
The efforts that continue to be deterrents: inadequate facilities and support systems (transportation), lack of spouse opportunities, lack of education opportunities for children, lack of group practice opportunities and consultations, economic disadvantages of practicing in areas of high poverty and unemployment "or in which the entire business and financial infrastructure fails to thrive." Bruce and Norton, Improving Rural Health P 168 1984
To those medical schools who are planning to improve their efforts in rural development it is suggested that a broad-brush approach be used in which faculty, students, and administrative officials equally are expected to participate in planning and implementing the program. There must be a serious and visible commitment from the medical school to make a contribution to rural medicine and to support the existing rural practitioners. To those legislative groups: finance properly the regional educational centers, sponsor incentive programs for rural hospitals, clinics, and professionals which have been carefully coordinated with the educational ventures and look at better ways to support rather than undercut rural medical care. To professional societies: address professional isolation, CME, the need for support groups and consultations. To rural communities: do not rely on outside efforts, work with the leadership of your town to analyze problems and carry out a logical plan to remedy the problems and work to develop new leaders to carry on. Bruce and Norton, Improving Rural Health P 168 – 169 1984
The interdependence of actions in the several sectors of health service has become increasingly recognized as necessary for rural improvements. Programs for facility construction, manpower expansion, economic support, and quality promotion are all obviously intertwined. These actions, in turn, are all interdependent with general social changes in agriculture, employment, transportation, education, social security, and other spheres. Reaching goals in any one of these sectors usually depends on parallel actions in several of the others Milton I. Roemer, Rural Health Care, C.V. Mosby Co. St. Louis, 1976
Friday I lectured neurology residents on End-of-Life care and found myself weaving community medicine into my talk because those residents had never heard the basics. And two weeks ago, a very bright young woman in medical school called me to ask about Family Medicine--she listened and was intrigued by the community part. Takes sophistication and self-confidence that one has mastered the basics of medicine to appreciate community medicine. Allene B. Jackson, M.D.
If you don’t feel comfortable with the basics, you won’t be able to move to the more advanced levels such as problem solving involving the community. Both Osler and Flexner and Medical School Deans at Tufts and other medical schools in past decades have made statements to the effect that the best students and doctors should choose rural practice, for they are the ones most capable of handling this kind of challenge - Robert C. Bowman, M.D. 2001
The small town needs the best and not the worst doctor procurable, for the country doctor has only himself to rely on. He cannot in every pinch hail specialist and nurse. -Dr. Abraham Flexner 1910 "Advancement of Teaching Medical Education in the United States and Canada"
“On his own skill, knowledge, resourcefulness, the welfare of his patient altogether depends. The rural district is therefore entitled to the best trained physician that can be induced to go there." -Dr. Abraham Flexner 1910 "Advancement of Teaching Medical Education in the United States and Canada"
I think it is difficult for young physicians who have not worked in a rural setting, and some older doctors who have (But have only seen one way of doing it), to understand that it is not "Family" or "Practice" but rather the effective integration of the two. There are many models for creating protected time for personal and family space in any setting, especially rural, and the only physicians who make it long-term in any setting are those who either ignore/neglect family or practice, or those who find incredible fulfillment by learning to integrate their lives. -- Randy Longenecker ³A Reflective Practitioner in a Rural Setting² 2001
The residency is a period of unbelievable professional growth and development, and with good fortune, may even be accompanied by comparable logarithmic personal enlargement. The resident should make a knowing and informed commitment to be a physician: to take care of patients with compassion, justice, honor, dignity, scholarship, and devotion Solomon Papper M.D, Doing Right 1983
The cultivated general practitioner. May this be the destiny of a large majority of you!…You cannot reach any better position in a community; the family doctor is the man behind the gun, who does our effective work. That his life is hard and exacting; that he is underpaid and overworked; that he has but little time for study and less for recreation–these are the blows that may give finer temper to his steel, and bring out the nobler elements in his character. "The Student Life: A Farewell Address to Canadian and American Medical Students." Medical News, New York, 87:625, 1905.
Physicians occupy an unusual spot in the social structure of rural communities. From an economic standpoint, they are successful entrepreneurs, well-paid business people similar to bankers and lawyers. On the other hand, they are also social servants like policemen or teachers, just as essential to the welfare and functioning of the community but paid for through a fee-for-service mechanism outside of local community control. This anomalous status requires some fairly innovative interpersonal and structural relationships to strike a workable balance. Rosenblatt and Moscovice, 1982
Building a community-responsive rural practice is endless work, a job that inevitably becomes as frustrating as it is rewarding. It requires a large tolerance for uncertainty and willingness to risk. One must deal effectively and tactfully with a variety of constituencies, any one of which can enhance or threaten the success of the venture. These include community people - supporters and opponents - local physicians, government officials, a hospital, one or more funding sources, a new staff and, of course, patients and their families. Not everyone is enthusiastic for the new practice or empathetic with its leaders- who are at all times expected to maintain their own idealism, energy, and optimism. New rural health centers are fragile entities, both economically and politically. When they finally succeed in becoming established it is usually because their people-leaders, staff, board members-were as stubbornly determined as they were resourceful. Donald L. Madison, 1980
This community study lends support to the belief that the ability of a community to attract physicians is closely related to the ability of that community to confront problems and take necessary actions – Bruce and Norton, Improving Rural Health 1984 p 66
The appalling cost to both the physician and to the rural community of this mismatch has not been well described. The young physician and his family moves to the town in good faith, making a long-term commitment. Within weeks or months it becomes apparent that the expectations of the doctor, and sometimes the town, are not to be realized. The agonizing decisions then begin whether to sever the relationship... For the rural community the trauma is almost as great: it is easier in most instances to be perennially without a physician than to find one, go through the process of change in adapting to a new one, lose the doctor and start the entire cycle over again. - Tom Bruce in Improving Rural Health
A clear message emerging from the extensive research that has looked at what factors influence physicians' decisions about where to practice medicine is that matters affecting the lives of spouses and children are among the most important considerations. -Barer Stoddart 1999
Communities do not have the luxury of remaining ignorant about the intricacies of medical practice. Unless they understand the tribulations and rewards of country practice, they will be unable to attract and retain people with the spectrum of skills that rural areas require. Rosenblatt and Moscovice 1982 Rural Health Care. John Wiley and Sons, New York, 1982
It is a basic consideration that the Rural Medical Development Program could have achieved on or both of the following, recruitment and/or retention in rural communities. It is the considered judgment of the program staff members after several years of work in this field that recruitment represents about 20% … and retention 80%… if all of the communities who had recruited physicians over the past years had been able to keep them, there would be no problem of access to rural medical care today. Bruce and Norton, Improving Rural Health P 162 1984
The interdependence of actions in the several sectors of health service has become increasingly recognized as necessary for rural improvements. Programs for facility construction, manpower expansion, economic support, and quality promotion are all obviously intertwined. These actions, in turn, are all interdependent with general social changes in agriculture, employment, transportation, education, social security, and other spheres. Reaching goals in any one of these sectors usually depends on parallel actions in several of the others Milton I. Roemer, Rural Health Care, C.V. Mosby Co. St. Louis, 1976
Change is always more troublesome than sitting still. Change is most easily accomplished at the medical school-college interface or in the first two years of medical school. Innovation at this level will never have much effect on the educational program, because the majority of a doctor's education comes after that period of time. Any significant change will have to affect the clinical years of medical school, internship, residency, and postgraduate education. Eugene A. Stead, Jr., M.D. 1982
In its meeting in June last year the AMA added two principles to its Code of Ethics. One of those, Principle IX, says "A Physician Shall Support Access to Medical Care for All People." It will be interesting to see how widely known and accepted that change becomes and what practical implication it has for policy, lobbying, and outcomes in real terms. It might be interesting for those of us who support the idea to challenge the AMA to "walk the walk" in addition to "talking the talk." Stuart Sprague, PhD
RPAP (MN) builds bridges of good will between the University and rural doctors. Many physicians recall the days when the hapless and hopeless referring LMD was dismissed with scorn at the professor's grand rounds. Times have changed! Monthly University visits have done much to dispel the doubts. When men of professional stature… come out to the rural hospital, make rounds, break bread, and discuss common problems with the local medical staff, new bonds of understanding grow quickly between small town and gown. JK Heid 1979
"When someone is in the dean's office keeps hammering away on something it is amazing how some of the most resistant faculty suddenly take for granted that it is going to change." -Mayer 1990
Will we be like many of our physician leaders who are focusing on dollars and control and position or will we continue to embrace patient care advocacy and teaching values to learners. I think what we can all agree upon is that reflection, re-evaluation and change is necessary. Barbara Starfield, as well as many other knowledgeable leaders, has documented that primary care is not delivering on its promise. Our founders are crying out for a new paradigm. Doctors McWhinney, Carmichael, White, those at Keystone (AAFP retreat), et al. are proposing and airing their ideas. To me, they are not attempting to write in stone, but are raising the bar on future negotiations for a change process. We must consider their words. Times are changing, there are many warning signs, and the public is growing restless. In my opinion, the concepts presented by these leaders can be a beginning point for a new and necessary revolution in family medicine philosophy. Lead and the warriors will follow. Lawrence Silverberg, M.D. 2001
Never doubt that a group of thoughtful, committed citizens can change the world: Indeed it is the only thing that ever has..... Margaret Mead
